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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever
Under the guidance of
Dr. Vinay PGY3
Dr.Pavani PGY1
This is a case of 65 year old female, housewife, staying alone since 5 years.
HOPI
The patient is apparently asymptotic 20 years back
20 yrs ago
The patient had hyperthyroidism. Kept on Neocarbimazole 5mg Po OD
10 yrs ago
She had decreased APETITE for which she went to local hospital. She was diagnosed to be type 2 DM and was kept on OHA
Since 1 week
She complains of high grade fever associated with chills and rigors
Since 2 days
Decreased food intake and missed OHAs
Difficulty in walking
weakness of upper and lower limbs
Passing stools and urine in her clothes
Past history
Diabetic since 10 years on Insulin
Hyperthyroidism since 20 years on neocarbimazole 5mg Po OD
PERSONAL HISTORY
DIET mixed
APETITE decreased
SLEEP adequate
BOWEL AND BLADDER MOVEMENTS involuntary
ADDICTIONS none
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
The patient is coherent conscious cooperative well oriented to time place and person
She is thin built and moderately nourished
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Edema absent
Lymphadenopathy absent
VITALS
Pulse 79
BP 120/80
RR 20
Temperature 99.4
Spo2 83%
GRBS 167
SYSTEMIC EXAMINATION
CVS- S1 S2 heard. No other sounds heard
RS -normal vesicular breath sounds heard
PA- soft and non tender
CNS- higher motor functions intact
Diagnosis
?Diabetic Keto acidosis
INVESTIGATIONS
O+ve
16/8/22
FBS LFT AND LIPID PROFILE
18/8/2022
22/8/2022
18/8/2022
ABG
16/8/22
PH 7.347
PCO2 28mmhg
PO2 81.1 mmhg
So2 93.7
HCO3 16.9
GRBS 592
17/8/22 5.42 am
Ph 7.42
PCO2 24.5
Po2 64.2
So2 92.9
HCO3 18.3
18/8/22
Ph7.401
PCO2 26.3
Po2 71.7
So294.6%
HCO3 18.1
20/8/22
Ph 7.47
PCO2 28.9
Po2 68.9
HCO3 20.9
16/8/2022
18/8/2022
19/8/2022
ECG
USG
2D ECHO
Culture and sensitivity
TREATMENT
Inj HAI 6 ml/hr (from 10pm to 1 am)
4 ml/hr (from 1 am )
Neocarbimazole 5mg PO OD
Iv NS 100ml/hr
BP/pulse/RR/GRBS charting every 2 hrly
Discharge summary
Soap notes
DAY 1
Yesterday's admission ICU BED -2
17/08/2022
S:SOB +
O:
Patient is conscious,coherent and cooperative
PR-82bpm
RR-26cpm
BP-130/80mm Hg
Temp-97°F
GRBS-163mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,clear
P/A-soft and non tender
A:Acute pain abdomen under evaluation
P:
1.NBM till further order
2.IVF 10 NS@100 ml/hr
3.INJ.TRAMADOL 100 ml IV
4.INJ.NORADRENALINE 6 ml/hr
5.RT
DAY 2
ICU BED NO-3 65 YEAR OLD FEMALE
Admitted on 16/08/2022
18/08/2022
S:SOB+,Fever since yesterday
O:
Patient is conscious,coherent and cooperative
PR-82bpm
RR-36cpm
BP-100/60mm Hg
Temp-100.6°F
GRBS-156mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,wheeze
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
P:
1.IVF 10 NS
10 5%dextrose @100ml/hr
2.INJ.ZOFER 4mg IV/TID
3.BP/PR/RR/GRBS charting-2nd hourly
4.Intermittent NIV
5.INJ.PIPTAZ 4.5gm/IV/BD
6.TAB.AZITHROMYCIN 500 mg/PO/OD
7.INSULIN
8.NEBULISATION WITH BUDECORT DUOLIN 6th hourly
DAY 3
ICU BED NO-3 65 YEAR OLD FEMALE
Admitted on 16/08/2022
18/08/2022
S:SOB+,Fever since yesterday
O:
Patient is conscious,coherent and cooperative
PR-82bpm
RR-36cpm
BP-100/60mm Hg
Temp-100.6°F
GRBS-156mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,wheeze
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
P:
1.IVF 10 NS
10 5%dextrose @100ml/hr
2.INJ.ZOFER 4mg IV/TID
3.BP/PR/RR/GRBS charting-2nd hourly
4.Intermittent NIV
5.INJ.PIPTAZ 4.5gm/IV/BD
6.TAB.AZITHROMYCIN 500 mg/PO/OD
7.INSULIN
8.NEBULISATION WITH BUDECORT DUOLIN 6th hourly
DAY 4
ICU BED NO-3 65 YEAR OLD FEMALE
Admitted on 16/08/2022
Day 4 19/08/2022
S:SOB+
O: No fever spikes since yesterday
Patient is conscious,coherent and cooperative
PR-85bpm
RR-21cpm
BP-120/90mm Hg
Temp-98.4°F
GRBS-12AM-87mg/dl
8AM-159 mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,left basal crypts
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
Left lower lung consolidation
P:
1.IVF 10 NS
10 5%dextrose @100ml/hr
2.INJ.ZOFER 4mg IV/TID
3.BP/PR/RR/GRBS charting-2nd hourly
4.Intermittent NIV
5.INJ.PIPTAZ 4.5gm/IV/BD
6.TAB.AZITHROMYCIN 500 mg/PO/OD
7.INJ.HAI acc to GRBS charting
8.NEBULISATION WITH BUDECORT DUOLIN 6th hourly
9.inj neomal 1gm IV
ICU BED NO-3 65 YEAR OLD FEMALE
Admitted on 16/08/2022
Day 5 20/08/2022
S:SOB subsided, fever subsided
O: No fever spikes since yesterday
Patient is conscious,coherent and cooperative
PR-112bpm
RR-33cpm
BP-120/50mm Hg
Temp-98.8°F
GRBS trend
8am-159mg/dl 6 units given
12pm - 200mg/dl
8pm- 135mg/dl 6 units given
10pm-96mg/dl
2am-87mg/dl
CVS-S1 and S2 +,no added sounds
R/S-BAE+,wheeze
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
Right lower lobe consolidation
P:
1.IVF 10 NS
10 5%dextrose @100ml/hr
2.INJ.Magnex forte 1.5 gm iv bd
3.BP/PR/RR/GRBS charting-2nd hourly
4.Intermittent NIV
5.INJ.PIPTAZ 4.5gm/IV/BD
6.TAB.AZITHROMYCIN 500 mg/PO/OD
7.INSULIN as per GRBS
8.NEBULISATION WITH BUDECORT DUOLIN 6th hourly
Day 6
Amc-65 YEAR OLD FEMALE
Admitted on 16/08/2022
Day 6 21/08/2022
S:SOB subsided, fever subsided
O: No fever spikes since yesterday
Patient is conscious,coherent and cooperative
PR-72bpm
RR-22cpm
BP-120/80mm Hg
Temp-98.°F
GRBS trend
6am-89mg/dl
8am - 4units HAI given
2pm- 292mg/dl 10 units given
10pm-143mg/dl 6 units given
CVS-S1 and S2 +,no added sounds
R/S-BAE+,wheeze
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
Right lower lobe consolidation
P:
1)Inj piptaz 4.5gm iv bd
2)inj pan 40mg iv
3)tab azithromycin 500mg Po OD
4)BP/pr/RR every 4th hourly
5)tab dolo 650mg Po tid
DAY 7
ICU BED NO-3 65 YEAR OLD FEMALE
Admitted on 16/08/2022
Day 7 22/08/2022
S:SOB subsided, fever subsided
O: No fever spikes since yesterday
Patient is conscious,coherent and cooperative
PR-102bpm
RR-cpm
BP-120/60mm Hg
Temp-98.°F
GRBS trend
8am-194mg/dl
2pm- 237mg/dl
4pm-128mg/dl
8pm-284mg/dl 10 units
CVS-S1 and S2 +,no added sounds
R/S-BAE+,wheeze
P/A-soft and non tender
A:uncontrolled sugars with type 2 DM
Right lower lobe consolidation
P:
1)Inj piptaz 4.5gm iv bd
2)inj pan 40mg iv
3)tab azithromycin 500mg Po OD
4)BP/pr/RR every 4th hourly
5)tab dolo 650mg Po tid
- nebulisation Duolin buds per 12 th hrly
- Tab glimi m1 Po/od @ 8 am
- High protein diet 2 egg whites / day
- Tab livogen 120 mg Po/bd
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